CASE REVIEW
Femoroacetabular Impingement
in a Soccer Player
James Timothy Lee, MS, ATC and James Francis Fiechtl, MD • Vanderbilt University
Medical Center
H
ip and groin injuries, which account
for 5–6% of reported injuries,1 are prevalent among adult athletes. In recent years,
an increase in acetabular labral tears and
cartilage damage due to femoroacetabular
impingement (FAI) has been documented.1
FAI can result from either a “pincer” or
a “cam” mechanism.
The pincer mechanism
Key Point
is the result of excessive bony projection
Femoroacetabular impingement is often
of the acetabular rim,
misdiagnosed as a soft tissue injury.
which decreases space
for the labrum moveA misdiagnosis may lead to months of
ment and produces a
misguided management.
shearing effect. CamSurgical intervention is required to decomtype impingement is the
press the impingement.
result of a nonspherical
femoral head and an
A structured rehabilitation program is
abnormal head-neck
essential for a safe return to play.
offset in relation to the
distal femur. Most FAI
patients have a combination of both the camtype and pincer-type impingement.2
Excess bone formation can cause excessive wear on the hip labrum and joint, which
can lead to degeneration of the labrum, articular cartilage damage, and osteoarthritis. The
cam impingement that is created by a prominent bony formation on the non-sperical
head of the femur typically results in selective
delamination of the articular surface of the
acetabulum and the labrum is unaffected.
The pincer impingement that is caused by
the bony projection of the acetabular rim
primarily affects the labrum, and secondarily
results in articular damage to the acetabulum.3 Research has demonstrated that camtype FAI is more common among men and
among individuals with diminished internal
rotation of the hip.4 Prevention programs
for FAI do not currently exist. Conservative
treatment consists of early recognition of FAI
symptoms, management of pain, and modification of activities. Surgical intervention is
indicated if the individual is unresponsive to
conservative treatment.5
Case History
A 22-year old male NCAA Division I soccer
player reported having experienced right
hip pain during pregame warm-up activity.
The athlete had been sitting and sleeping
on a bus for ten hours in a hyper flexed hip
position the previous day. He complained
of inability to produce power through his
hip to kick or punt the soccer ball. Pain was
localized on the lateral aspect of his hip over
the greater trochanter, with pain radiating
down the ilio-tibial band (IT band). He denied
any previous injury to his right hip. Manual
muscle tests were normal for strength but
elicited pain in his lateral hip and groin. The
athlete was unable to play in the game. The
athletic trainer assessed the injury as IT band
tightness, and the athlete was treated with
stretching and cryotherapy. He was referred
to the team physician for evaluation of hip
pain at 2 days postinjury.
© 2012 Human Kinetics - IJATT 17(6), pp. 40-43
40  november 2012
international journal of Athletic Therapy & training
Diagnosis and Treatment
The differential diagnoses for lateral hip and groin
pain in a soccer player is broad, including IT band
syndrome, greater trochanteric bursitis, rectus femoris
strain/tear, iliopsoas strain, iliopsoas bursitis, adductor
strain, athletic pubalgia, inguinal hernia, hip labral tear,
and avascular necrosis of the femoral head.6 Due to
the localization of symptoms to the lateral hip area, the
decision was made to start with conservative treatment
that consisted of modalities, soft tissue mobilization,
and progressive resistance exercises for IT band syndrome and greater trochanteric bursitis. The athlete
was restricted to pain-free activity.
After three weeks of conservative treatment, the
athlete had demonstrated little improvement and his
pain had migrated in an anterior direction. Pain was
localized over the anterior inferior iliac spine (AIIS)
and was exacerbated by a resisted straight-leg raise.
Plain radiographs revealed an apparently old avulsion
injury to the AIIS (Figures 1 and 2). The radiographs
also revealed a subtle cam-type deformity of the
femoral neck. The athlete’s rehabilitation program was
subsequently modified to focus on hip flexion and hip
adduction straight-leg raises that were resisted by ankle
weights and elastic tubing. Bridges, planks, and lower
abdominal isometrics were implemented to improve
core strength. The athlete was restricted from performing any exercises that increased his pain.
After an additional three weeks of rehabilitation, the
athlete had failed to improve and still could not generate
power when kicking. Magnetic resonance imaging with
intra-articular contrast of his right hip was obtained,
which confirmed the existence of a cam-type deformity
of the femoral neck, with a significant osseous abnormality and extensive labral tearing (Figures 3 and 4).
Because bupivacaine was administered prior to performance of the diagnostic imaging procedure, the athlete
Figure 1 Plain radiograph, AP view, of the right hip. The straight arrow
points to the old AIIS avulsion and the angled arrow points to the osseous bump consistent with a CAM type deformity of the femoral neck.
Figure 2 Plain radiograph, Lateral view, of the right hip. The straight
Figure 3 MR-arthrogram, coronal view, of the right hip. The straight
Figure 4 MR-arthogram, axial view, of the right hip. The straight arrow
arrow points to the labral tear and the angled arrow points to the osseous bump consistent with a CAM type deformity of the femoral neck.
points to the labral tear and the angled arrow points to the osseous
bump consistent with a CAM type deformity of the femoral neck.
international journal of Athletic Therapy & training
arrow points to the old AIIS avulsion and the angled arrow points to the
osseous bump consistent with a CAM type deformity of the femoral neck.
november 2012  41
experienced relief of pain for several hours afterward.
Due to the failure of conservative management and the
pain relief that was produced by intra-articular injection
of bupivacaine, the athlete was referred to an orthopedic
surgeon with specialized expertise in hip arthroscopy.
Surgical Intervention
An arthroscopic procedure was performed that
included debridement, labral repair, and femoroplasty
to address the cam-type impingement. Complex radial
fibrillated tears in both the anterior and lateral portions of the labrum were evident, along with grade 3
and grade 4 chondral damage on the acetabular rim.
A pincer lesion was identified along the anterolateral
rim of the acetabulum, which was combined with a
substantial cam lesion. Debridement of the pincer
lesion was necessary to preserve the repaired labrum.
Reshaping the femoral head alleviates the cam-type
impingement caused by the non-spherical shape of
the head of the femur.
Following capsulotomy, the pincer lesion was
identified, which was concentrated around the prominence of the anteroinferior iliac spine. The bone was
recontoured through removal to a depth of 4–5 mm.
The main substance of the labrum was preserved,
which was reattached after the pincer lesion had been
removed. A dense synovial metaplasia was debrided
from the acetabular fossa while preserving the ligamentum teres. A femoroplasty was performed to remove 6
mm at the apex of the cam lesion with distal tapering.
The impingement lesion was carefully decompressed,
with special attention to avoid a notch in the femur or
to leave a potential stress riser.
Rehabilitation
The athlete’s rehabilitation followed a 12-week protocol
that was divided into four phases. Phase 1 of the protocol was focused on restoration of range of motion and
strength during the first 3 weeks following surgery. The
athlete’s range of motion was limited to 90 degrees of
hip flexion and 0 degrees of external rotation. He was
allowed to partially bear weight (~50%) for the first
four weeks following surgery.
Phase 2 of the protocol was implemented during
the fourth through sixth postsurgery weeks. Hip range
42  november 2012
of motion was limited to 105 degrees of flexion and
20 degrees of external rotation. Full weight bearing
should be encouraged at this stage, assuming that no
gait deviations exist. Progressive resistance exercises
for the core and lower extremity were advanced as
tolerated. Joint mobilizations and hip stretching were
performed, and the athlete was allowed to utilize a
stationary bike and an elliptical trainer as tolerated.
Phase 3 of the protocol corresponded to the seventh and eighth postsurgery weeks. The goals were to
restore full range of motion in the hip, while continuing to achieve gains in muscular endurance, strength,
proprioception, and balance. Cardiovascular endurance
exercise was initiated during this phase. Joint mobilizations and hip stretching were continued. The athlete
regained full range of motion at 7 weeks postsurgery.
He performed one hour of cardiovascular exercise 5
days per week, utilizing both a stationary bike and an
elliptical machine.
Upon initiation of phase 4 of the rehabilitation
protocol at nine weeks postsurgery, the athlete demonstrated hip flexion strength that was greater than
70% of that for the uninvolved side, and hip adduction, extension, internal, and external rotation strength
that was greater than 80% of that for the uninvolved
side. Treadmill jogging, agility drills, plyometric exercises, and resistance band walking patterns were
subsequently initiated. Running speed was progressed
until the athlete could perform forward and backward
sprints of 10, 20, and 30 yards without pain or limitation, and running distance was progressed up to four
miles on two to three days per week. The athlete began
to perform basic soccer-related drills and goalie-specific
drills involving passing and catching the ball. The
intensity of the sport-specific activities was increased
on the basis of the athlete’s tolerance. Criteria for a
full return to competition included full hip range of
motion, hip strength equal to that of his uninvolved
side, and the ability to perform all sport-specific drills
without pain. The athlete was cleared for participation
at 5 months postsurgery, and he was able to return to
college athletics without restrictions.
Acknowledgment
Special thanks to Dr. J.W. Thomas Byrd for his expertise
and assistance with this case and manuscript. 
international journal of Athletic Therapy & training
References
1.Keogh MJ, Batt ME. A review of femoroacetabular impingement in
athletes. Sports Med. 2008;10:863-878.
2. Ejnisman L, Philippon MJ, Lertwanich P. Femoroacetabular impingement: the femoral side. Clin Sports Med. 2011;30:369-377.
3.Byrd JWT, Jones KS. Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Clin Orthop.
2009;467:739-746.
4.Hack K, Di Primio G, Rakhra K, Beaule PE. Prevalence of cam-type
femoroacetabular impingement morphology in asymptomatic volunteers. J Bone Joint Surg Am. 2010;92:2436-2444.
5. Byrd, JWT. Femoroacetabular impingement in athletes, part II: treatment and outcomes. Sports Health. 2010; 2:403-409.
6.Tibor, LM, Sekiya, JK. Differential diagnosis of pain around the hip
joint. Arthroscopy. 2008;24:1407-1421.
James Timothy Lee is a Certified Athletic Trainer at Vanderbilt University Medical Center in Nashville, TN.
James Francis Fiechtl is an assistant professor of Emergency Medicine
at Vanderbilt University Medical Center, Nashville, TN.
Joe J. Piccininni, EdD, CAT(C), The University of Toronto, is the Report
Editor for this article.
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